Washington Credentialing

Standardization Group

(Month Date, Year)

(Delegate Contact Name

Street Address

City, State, Zip)

RE:DELEGATED CREDENTIALING ANNUAL AUDIT CONFIRMATION

Dear(Delegate Contact Name):

This letter will confirm your annual delegated credentialing audit has been scheduled for(Month Date, Year @ Time),it is expected to last for three hours, and will be performed by the WCSG Shared Delegation Audit team.

Please forward electronic copies of the documents listed below on (Month Date, Year)to all the health plans that delegate credentialing to (Group Name)and participate in the WCSG Shared Delegation Audit program. These health plans are(Health Plan names).If you have any updates to the contracted health plans, please let us know.

  • Current Credentialing program/plan description and/or policies and procedures (current program/plan description and/or policies and procedures should meet 2017 NCQA standards which took effect 07/01/17).
  • Current list of all practitioners, including their name, specialty, initial credentialing committee decision date and most recent recredentialing committee decision date. Please remove from your lists all Anesthesiologists (including CRNAs), Emergency Medicine, Hospitalists, Neonatologists, Pathologists, Radiologists, and Locum Tenens providers.
  • Current list of the Credentialing Committee/Board members, including their name, title and specialty.
  • Current Ownership and/or Controlling Interest Disclosure Form
  • Copies of sub-delegation agreement(s) currently in effect and oversight result(s) of sub-delegates for the past 12 months, as applicable.
  • Copies of ongoing monitoring logs, at a minimum:
  • State license sanction log
  • Office of the Inspector General sanction/exclusion log
  • Medicare Opt-Out
  • SAM sanction/exclusion log
  • Answers to the Pre-Audit Questions on pages 2-4 of this letter.

If you choose to send the requested documents prior to the due date, please be aware that the list of practitioners and ongoing monitoring logs should not be sent more than 30 days prior to the scheduled audit.

Sincerely,

WCSG SDA Audit Team Lead

Shared Delegation Audit Team Members:

(Group Name)

Annual Delegated Credentialing Audit

(Month Date, Year)

Pre-Audit Questions

Please complete this document and submit by the due date.

Question / Response
Does your Organization review Policies and Procedures annually? / Yes No
When was the last time your organization revised the Policies and Procedures?
How does your organization notify practitioners of their rights (CR 1 Element B)? For example: cover letter, bylaws, etc.
Please provide a copy of the source used to notify practitioners of their rights.
Does your organization monitor, at least annually the credentialing and recredentialing processes for discriminatory practices? Monitoring involves tracking and identifying discrimination in credentialing and recredentialing processes.
Please make documentation available during on-site review. / Yes No
6.
7.
8. / How many PCP’s are on your roster?
How many Specialists are on your roster?
How many Allied Health Practitioners are on your roster?
Does your delegation with any of the participating plans include Medicare lines of business?
Does your delegation with any of the participating plans include Medicaid lines of business?
Does your organization allow for practitioners to Opt-Out of Medicare?
Does your organization use the OneHealthPort/Medversant application? / Yes No
Yes No
Yes No
Yes No
Does your organization use an electronic, online application for initial and/or recredentialing (other than the OneHealthPort/Medversant application)?
If yes, please describe: / Yes No
Does your organization use the WPA or OPCA Application for initial credentialing? / Yes No
Does your organization use the WPA or OPCA Attestation Questions for initial credentialing? / Yes No
Does your organization use the WPA or OPCA Attestation Questions for recredentialing? / Yes No
Does your organization have an Inpatient Coverage Plan if the provider does not have Hospital Privileges?
If yes, please provide a copy of the Inpatient Coverage Plan. / Yes No
Does your organization have its own Malpractice Coverage for their providers?
If yes, please provide a copy of the Malpractice Coverage. / Yes No
16.
17. / Does your organization have a DEA Coverage Plan for practitioners in the event they need one(i.e., registered to an out of state address, fee paid certificate paid for by another organization, practicing in a specialty that would otherwise require one, etc.)?
If yes, please provide a copy of the DEA Coverage plan.
Does your organization submit all credentialing and recredentialing files to the Credentialing Committee for review/approval?
If no, does your organization submit “clean files” to the Medical Director for review/approval?
How does the Medical Director document review/approval?
Office Site Visits:
Have there been complaints about physical access/appearance that met/exceeded threshold?
Has your organization conducted site visits of offices that meet/exceeded threshold?
Was any corrective action necessary?
Has your organization evaluated the effectiveness of the actions at least every 6 months?
Has your organization documented follow-up visits for those sites that had subsequent deficiencies?
If yes to any of the above, please make documentation available during on-site review. / Yes No
Yes No
Yes No
Yes No
Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
How frequently does your Credentialing Committee meet?
  • For example, monthly, bi-monthly, quarterly
In what capacity does your Credentialing Committee meet?
  • For example, in person, conference call, web conference

Does your organization use the state licensing agency to verify education/training?
If yes, please provide a copy of the current written confirmation from the state licensing agency that it performs primary source verification. / Yes No
Are there provider types on your Organization’s roster that are not credentialed?
If yes, please list the type of provider: / Yes No
Since last year’s audit, has your organization altered the conditions of a practitioner’s participation based on quality of care and/or service?
If yes, make file(s) available during on-site review. / Yes No
Since last year’s audit, has your organization reported a practitioner’s suspension or termination to the appropriate authorities?
If yes, make file(s) available during on-site review. / Yes No
Does your organization collect and make available performance monitoring data at recredentialing? This is a CMS requirement for Medicare. CMS requires that performance data such as member complaints/grievances and quality activities be considered as part of the recredentialing process. Please describe how performance monitoring data is documented in the credentialing file at time of the recredentialing decision.
If data is not kept permanently in the credentials file, report(s) must be made available during the on-site audit for all files selected. / Yes No N/A
Does your organization sub-delegate any credentialing activities?
If yes, what is the name of the sub-delegate?
Is the sub-delegate another medical group, CVO or other?
What is the effective date of the sub-delegation arrangement?
What activities are sub-delegated (e.g., processing applications, PSV, decision-making)?
Do you sub-delegate these activities for initial credentialing, recredentialing or both?
Is the sub-delegate NCQA certified? (If yes, make documentation of NCQA certification available during on-site review.)
Does the sub-delegate submit regular credentialing activity reports? (If yes, make reports available during on-site review.)
Does your organization annually review the sub-delegate’s policies and procedures? (If yes, make reports available during on-site review.) / Yes No
Yes No
Yes No
Yes No

Updated 05/31/17